Types of Psychotherapy
Psychotherapy (psychological therapy or talking therapy) is the use of methods, particularly when based on regular , to help a person change behavior and overcome problems in desired ways. Psychotherapy aims to improve an individual's and , to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and . Certain psychotherapies are considered for treating some diagnosed s. Others have been criticized as . There are over a thousand different psychotherapy techniques, some being minor variations, while others are based on very different conceptions of psychology, ethics (how to live), or techniques. Most involve one-to-one sessions, between client and therapist, but some are conducted with , including . Psychotherapists may be such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapists may also come from a variety of other backgrounds, and depending on the may be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not). Definitions The term is derived from ( meaning "breath; spirit; soul") and therapeia ( "healing; medical treatment"). The defines it now as "The treatment of disorders of the mind or personality by psychological methods...", however, in earlier use it denoted the treatment of disease through hypnotic suggestion. The adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by : "Psychotherapy is the informed and intentional application of and derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable". Influential editions of a work by psychiatrist defined psychotherapy as a healing relationship using socially authorized methods in a series of contacts primarily involving words, acts and rituals—regarded as forms of and . Some definitions of overlap with psychotherapy (particularly in non-directive client-centered approaches), or counseling may refer to guidance for everyday problems in specific areas, typically for shorter durations with a less medical or 'professional' focus. refers to the use of physical changes as injuries and illnesses, and to the use of a person's social environment to effect therapeutic change. Psychotherapy may address as a significant part of someone's mental / psychological life, and some forms are derived from spiritual philosophies, but practices based on treating the spiritual as a separate dimension are not necessarily considered as traditional or 'legitimate' forms of psychotherapy. Historically, psychotherapy has sometimes meant "interpretative" (i.e. ) methods, namely , in contrast with other methods to treat psychiatric disorders such as behavior modification. Psychotherapy is often dubbed as a "talking therapy", particularly for a general audience, though not all forms of psychotherapy rely on . Children or adults who do not engage in verbal communication (or not in the usual way) are not excluded from psychotherapy; indeed some types are designed for such cases. Delivery Psychotherapy may be delivered in person (one on one, or with couples, or in groups), over the phone, via , or . It has not been established whether the effectiveness of psychotherapy administered online, over video chat for instance, is comparable to that delivered within in-person meetings: Clear, consistent trends from empirical research are lacking regarding the efficacy of online therapy - Australian Counselling Association. The Victoria Government's Health Agency has awarded no mental health app with scores greater than 3 stars out of 5 for effectiveness. One reason for this is that online Cognitive Behavioural Therapy programs have poor "adherence" compared to face-to-face programs. That means that many users do not "stick to" the program as prescribed. They may uninstall the app or skip days, for instance. Treatments duration According to the American Psychological Association, experts suggests that those who have had two depressive episodes in recent years, or three episodes over their life, have to get treated on an ongoing basis to prevent recurrent depression: At least 60% of individuals who have had one depressive episode will have another, 70% of individuals who have had two depressive episodes will have a third, and 90% of individuals with three episodes will have a fourth episode. Regulation Psychotherapists traditionally may be: like psychologists and psychiatrists; professionals from other backgrounds (family therapists, social workers, nurses, etc.) who have trained in a specific psychotherapy; or (in some cases) academic or scientifically-trained professionals. are trained first as physicians, and—as such—they may prescribe ; and specialist psychiatric training begins after medical school in psychiatric residencies: however, their specialty is in mental disorders or forms of mental illness. have specialist doctoral degrees in psychology with some clinical and research components. Other clinical practitioners, , mental health counselors, pastoral counselors, and nurses with a specialization in mental health, also often conduct psychotherapy. Many of the wide variety of psychotherapy training programs and institutional settings are multi-professional. In most countries, psychotherapy training are all at a post-graduate level, often at a master's degree (or doctoral) level, over a 4-year period, with significant supervised practice and clinical placements. Such professionals doing specialized psychotherapeutic work also require a program of continuing professional education after basic professional training. There is a 2013 listing of the extensive professional competencies of a European psychotherapist, developed by the European Association of Psychotherapy (EAP). As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of —and the limited circumstances in which it may need to be broken for the protection of clients or others—is enshrined in the regulatory psychotherapeutic organizations' codes of ethical practice. Examples of when it is typically accepted to break confidentiality include when the therapist has knowledge that a child or elder is being physically abused; when there is a direct, clear and imminent threat of serious physical harm to self or to a specific individual. Europe As of 2015, there are still a lot of variations between different European countries about the regulation and delivery of psychotherapy. Several countries have no regulation of the practice or no protection of the title. Some have a system of voluntary registration, with independent professional organizations, while other countries attempt to restrict the practice of psychotherapy to 'mental health professionals' (psychologists and psychiatrists) with state-certified training. The titles that are protected also vary. The (EAP) established the 1990 Strasbourg Declaration on Psychotherapy, which is dedicated to establishing an independent profession of psychotherapy in Europe, with pan-European standards. The EAP has already made significant contacts with the European Union & European Commission towards this end. Given that the has a primary policy about the free movement of labor within Europe, European legislation can overrule national regulations that are, in essence, forms of restrictive practices. In Germany, the practice of psychotherapy for adults is restricted to qualified psychologists and physicians (including psychiatrists) who have completed several years of specialist practical training and certification in psychotherapy. As psychoanalysis, psychodynamic therapy, and cognitive behavioral therapy meet the requirements of German health insurance companies, mental health professionals regularly opt for one of these three specializations in their postgraduate training. For psychologists, this includes three years of full-time practical training (4.200 hours), encompassing a year-long internship at an accredited psychiatric institution, six months of clinical work at an outpatient facility, 600 hours of supervised psychotherapy in an outpatient setting, and at least 600 hours of theoretical seminars. s may complete the specialist training for child and teenage clients. Similarly in Italy, the practice of psychotherapy is restricted to graduates in psychology or medicine who have completed four years of recognised specialist training. Sweden has a similar restriction on the title "psychotherapist", which may only be used by professionals who have gone through a post-graduate training in psychotherapy and then applied for a licence, issued by the . Legislation in France restricts the use of the title "psychotherapist" to professionals on the National Register of Psychotherapists, which requires a training in clinical psychopathology and a period of internship which is only open to physicians or titulars of a master's degree in psychology or psychoanalysis. Austria and Switzerland (2011) have laws that recognize multi-disciplinary functional approaches. In the , the government and considered mandatory legal registration but decided that it was best left to professional bodies to regulate themselves, so the (PSA) launched an Accredited Voluntary Registers scheme. Counseling and psychotherapy are not protected titles in the United Kingdom. Counsellors and psychotherapists who have trained and qualify to a certain standard (usually a level 4 Diploma) can apply to be members of the professional bodies who are listed on the PSA Accredited Registers. United States In some states, counselors or therapists must be licensed to use certain words and titles on self-identification or advertising. In some other states, the restrictions on practice are more closely associated with the charging of fees. Licensing and regulation are performed by various states. Presentation of practice as licensed, but without such a license, is generally illegal. Without a license, for example, a practitioner cannot bill insurance companies. Information about state licensure is provided by the . In addition to state laws, the American Psychological Association requires its members to adhere to its published Ethical Principles of Psychologists and Code of Conduct. The examines and certifies "psychologists who demonstrate competence in approved specialty areas in professional psychology". History Psychotherapy can be said to have been practiced through the ages, as medics, philosophers, spiritual practitioners and people in general used psychological methods to heal others. In the , by the 19th century, a movement (then meaning morale or mental) developed based on non-invasive non-restraint therapeutic methods. Another influential movement was started by (1734–1815) and his student (1751–1825). Called Mesmerism or animal magnetism, it would have a strong influence on the rise of and psychiatry as well as theories about . In 1853 introduced the term "psycho-therapeia" regarding how physicians might influence the mental states of sufferers and thus their bodily ailments, for example by creating opposing emotions to promote mental balance. cited the term and wrote about "psycho-therapeutics" in 1872, in which he also proposed making a science of . and colleagues in the " School" developed the concept of "psychotherapy" in the sense of using the mind to heal the body through , yet further. Charles Lloyd Tuckey's 1889 work, Psycho-therapeutics, or Treatment by Hypnotism and Suggestion popularized the work of the Nancy School in English. Also in 1889 a clinic used the word in its title for the first time, when and Albert Willem in renamed theirs "Clinique de Psycho-thérapeutique Suggestive" after visiting Nancy. During this time, travelling became popular, and such activities added to the scientific controversies around the use of hypnosis in medicine. Also in 1892, at the second congress of experimental psychology, van Eeden attempted to take the credit for the term psychotherapy and to distance the term from hypnosis. In 1896, the German journal Zeitschrift für Hypnotismus, Suggestionstherapie, Suggestionslehre und verwandte psychologische Forschungen changed its name to Zeitschrift für Hypnotismus, Psychotherapie sowie andere psychophysiologische und psychopathologische Forschungen, which is probably the first journal to use the term. Thus psychotherapy initially meant "the treatment of disease by psychic or hypnotic influence, or by suggestion". visited the Nancy School and his early practice involved the use of hypnotism. However following the work of his mentor —in particular a case where symptoms appeared partially resolved by what the patient, , dubbed a " "—Freud began focusing on conditions that appeared to have psychological causes originating in childhood experiences and the . He went on to develop techniques such as , , and analysis of the . His popular reputation as the father of psychotherapy was established by his use of the distinct term " ", tied to an overarching system of theories and methods, and by the effective work of his followers in rewriting history. Many theorists, including , , , , , , and , built upon Freud's fundamental ideas and often developed their own systems of psychotherapy. These were all later categorized as , meaning anything that involved the 's / influence on external relationships and the self. Sessions tended to number into the hundreds over several years. developed in the 1920s, and as a therapy became popularized in the 1950s and 1960s. Notable contributors were in South Africa, M.B. Shipiro and in Britain, and and in the United States. approaches relied on principles of , and to bring about therapeutic change in observable symptoms. The approach became commonly used for , as well as other disorders. Some therapeutic approaches developed out of the European school of . Concerned mainly with the individual's ability to develop and preserve a sense of meaning and purpose throughout life, major contributors to the field (e.g., , ) and Europe ( , , , , ) attempted to create therapies sensitive to common "life crises" springing from the essential bleakness of human self-awareness, previously accessible only through the complex writings of existential philosophers (e.g., , , , , ). The uniqueness of the thus also forms a vehicle for therapeutic inquiry. A related body of thought in psychotherapy started in the 1950s with . Based also on the works of and his , Rogers brought into mainstream focus. The primary requirement was that the client be in receipt of three core "conditions" from his counselor or therapist: unconditional positive regard, sometimes described as "prizing" the client's humanity; congruence authenticity/genuineness/transparency; and . This type of interaction was thought to enable clients to fully experience and express themselves, and thus develop according to their innate potential. Others developed the approach, like and in the creation of , as well as Marshall Rosenberg, founder of , and , founder of . Later these fields of psychotherapy would become what is known as today. Self-help groups and books became widespread. During the 1950s, originated (REBT). Independently a few years later, psychiatrist developed a form of psychotherapy known as . Both of these included relatively short, structured and present-focused techniques aimed at identifying and changing a person's beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Beck's approach used primarily the , and links have been drawn between ancient philosophy and these cognitive therapies. Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella term (CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborative (a form of reality-testing), and assessing and modifying core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A "third wave" of cognitive and behavioral therapies developed, including and , which expanded the concepts to other disorders and/or added novel components and exercises. However the "third wave" concept has been criticized as not essentially different from other therapies and having roots in earlier ones as well. Counseling methods developed include and . psychotherapies such as and do not impose definitions of mental health and illness, but rather see the goal of therapy as something constructed by the client and therapist in a social context. also developed, which focuses on family and group dynamics—and , which focuses on the spiritual facet of human experience. Other orientations developed in the last three decades include , , , , applied and the approach. A survey of over 2,500 US therapists in 2006 revealed the most utilized models of therapy and the ten most influential therapists of the previous quarter-century. Types Overview There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250; by 1996 more than 450; and at the start of the 21st century there were over a thousand different named psychotherapies—some being minor variations while others are based on very different conceptions of psychology, ethics (how to live) or technique. In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as an or approach. The importance of the , also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. addresses this and other core aspects thought to be responsible for effective psychotherapy. Sigmund Freud (1856–1939), a Viennese neurologist who studied with in 1885, is often considered the father of modern psychotherapy. His methods included analyzing dreams for important insights that layout of awareness of the dreamer. Other major elements of his methods, which changed throughout the years, included identification of childhood sexuality, the role of anxiety as a manifestation of inner conflict, the differentiation of parts of the psyche (id, ego, superego), transference and countertransference (the patient's projections onto the therapist, and the therapist's emotional responses to that). Some of his concepts were too broad to be amenable to empirical testing and invalidation, and he was critiqued for this by Jaspers. Numerous major figures elaborated and refined Freud's therapeutic techniques including Melanie Klein, Donald Winnicott, and others. Since the 1960s, however, the use of Freudian-based analysis for the treatment of mental disorders has declined substantially. Different types of psychotherapy have been created along with the advent of clinical trials to test them scientifically. These incorporate subjective treatments (after Beck), behavioral treatments (after Skinner and Wolpe) and additional time-constrained and centered structures, for example, interpersonal psychotherapy. In youth issue and in schizophrenia, the systems of family treatment hold esteem. A portion of the thoughts emerging from therapy are presently pervasive and some are a piece of the tool set of ordinary clinical practice. They are not just medications, they additionally help to understand complex conduct. Therapy may address specific forms of diagnosable , or everyday problems in managing or maintaining or meeting personal goals. A course of therapy may happen before, during or after (e.g. taking ). Psychotherapies are categorized in several different ways. A distinction can be made between those based on a and those based on a . In the medical model, the client is seen as unwell and the therapist employs their skill to help the client back to health. The extensive use of the , the diagnostic and statistical manual of mental disorders in the United States is an example of a medically exclusive model. The humanistic or non-medical model in contrast strives to depathologise the human condition. The therapist attempts to create a relational environment conducive to experiential learning and help build the client's confidence in their own natural process resulting in a deeper understanding of themselves. The therapist may see themselves as a facilitator/helper. Another distinction is between individual one-to-one therapy sessions, and , including and . Therapies are sometimes classified according to their duration; a small number of sessions over a few weeks or months may be classified as (or short-term therapy), others, where regular sessions take place for years, may be classified as long-term. Some practitioners distinguish between more "uncovering" (or " ") approaches and more "supportive" psychotherapy. Uncovering psychotherapy emphasizes facilitating the client's insight into the roots of their difficulties. The best-known example is classical psychoanalysis. by contrast stresses strengthening the client's coping mechanisms and often providing encouragement and advice, as well as reality-testing and limit-setting where necessary. Depending on the client's issues and situation, a more supportive or more uncovering approach may be optimal. Most forms of psychotherapy use spoken . Some also use various other forms of communication such as the written word, , , story or music. Psychotherapy with children and their parents often involves , dramatization (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting. There are also different formats for delivering some therapies, as well as the usual face to face: for example or . There have also been developments in computer-assisted therapy, such as for behavioral exposure, multimedia programs to each cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice. Humanistic These psychotherapies, also known as " ", are based on and emerged in reaction to both behaviorism and psychoanalysis, being dubbed the "third force". They are primarily concerned with the human development and needs of the individual, with an emphasis on meaning, a rejection of , and a concern for positive growth rather than . Some posit an inherent human capacity to maximize potential, "the tendency"; the task of therapy is to create a relational environment where this tendency might flourish. Humanistic psychology can, in turn, be rooted in —the belief that human beings can only find meaning by creating it. This is the goal of . Existential therapy is in turn philosophically associated with . , also known as client-centered, focuses on the therapist showing openness, empathy and "unconditional positive regard", to help clients express and develop their own . , originally called "concentration therapy", is an existential/experiential form that facilitates awareness in the various contexts of life, by moving from talking about relatively remote situations to action and direct current experience. Derived from various influences, including an overhaul of psychoanalysis, it stands on top of essentially four load-bearing theoretical walls: , dialogical relationship, field-theoretical strategies, and experimental freedom. A briefer form of humanistic therapy is the approach, introduced in 1998/9. It is a solution-focused intervention based on identifying emotional needs—such as for security, autonomy and social connection—and using various educational and psychological methods to help people meet those needs more fully or appropriately. Insight-oriented focus on revealing or interpreting processes. Most commonly referring to , of which is the oldest and most intensive form, these applications of encourage the verbalization of all the patient's thoughts, including , fantasies, and dreams, from which the analyst formulates the nature of the past and present unconscious conflicts which are causing the patient's symptoms and character problems. There are six main schools of psychoanalysis, which all influenced psychodynamic theory: Freudian, , , , , and . Techniques for analytic have also developed. Cognitive-behavioral use techniques, including (also known as ), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. is one form of this approach. By nature, behavioral therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behavior ultimately has), probabilistic (viewing behavior as statistically predictable), (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions). focuses directly on changing the thoughts, in order to improve the emotions and behaviors. attempts to combine the above two approaches, focused on the construction and reconstruction of people's s, and s. Generally in CBT, the therapist, through a wide array of modalities, helps clients assess, recognize and deal with problematic and dysfunctional ways of thinking, emoting and behaving. The concept of "third wave" psychotherapies reflects an influence of , incorporating principles such as into interventions such as , , and for . (IPT) is a relatively brief form of psychotherapy (deriving from both CBT and approaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links between and social circumstances, helping to build social skills and social support. It aims to foster adaptation to current interpersonal roles and situations. Other types include / , , and therapies for specific disorders including therapies such as and ; therapies such as and ; therapies such as ; and therapies such as Seeking Safety. Systemic seeks to address people not just individually, as is often the focus of other forms of therapy, but in relationship, dealing with the interactions of groups, their patterns and dynamics (includes and ). is a type of systemic psychology. The term was first used around 1920 by , whose main contribution was the development of , in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the US, such as , who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably and Rickman, followed by , Main, and Bridger. The in Birmingham gave its name to what came to be called the two "Northfield Experiments", which provided the impetus for the development since the war of both social therapy, that is, the movement, and the use of small groups for the treatment of neurotic and personality disorders. Today group therapy is used in clinical settings and in private practice settings. Expressive Expressive therapy is any form of therapy that utilizes artistic expression as its core means of treating clients. Expressive therapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities , , , , , among others. Expressive therapists believe that often the most effective way of treating a client is through the expression of imagination in creative work and integrating and processing what issues are raised in the act. Postmodernist Also known as or . gives attention to each person's "dominant story" by means of therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful. posits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realization. does not accept that there is one single or correct way of looking at reality and therefore is considered a postmodernist approach. Other addresses the client in the context of a spiritual understanding of consciousness. (PPT) (since 1968) is a method in the field of humanistic and psychodynamic psychotherapy and is based on a positive image of humans, with a health-promoting, resource-oriented and conflict-centered approach. Hypnotherapy is undertaken while a subject is in a state of . Hypnotherapy is often applied in order to modify a subject's behavior, emotional content, and attitudes, as well as a wide range of conditions including: dysfunctional habits, anxiety, stress-related illness, pain management, and personal development. , part of the field of , focuses on the link between the mind and the body and tries to access deeper levels of the psyche through greater awareness of the and . There are various body-oriented approaches, such as Reichian ( ) character-analytic and orgonomy; neo-Reichian ; ; ; Ron Kurtz's psychotherapy; ; Biosynthesis psychotherapy; and Biodynamic psychotherapy. These approaches are not to be confused with or body-therapies that seek to improve primarily physical health through direct work (touch and manipulation) on the body, rather than through directly psychological methods. Some non-Western therapies have been developed. In African countries this includes harmony restoration therapy, meseron therapy and systemic therapies based on the . is an attempt to combine ideas and strategies from more than one theoretical approach. These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include , the , cyclical psychodynamics, systematic treatment selection, , , and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time. Child Counseling and psychotherapy must be adapted to meet the developmental needs of children. It is generally held to be one part of an effective strategy for some purposes and not for others. In addition to therapy for the child, or even instead of it, children may benefit if their parents speak to a therapist, take parenting classes, attend , or take other actions to resolve stressful situations that affect the child. is a highly effective form of psychotherapy that teaches parents skills to reduce their child's behavior problems. Many counseling preparation programs include courses in . Since children often do not have the ability to articulate thoughts and feelings, counselors will use a variety of media such as crayons, paint, clay, puppets, bibliocounseling (books), toys, board games, et cetera. The use of is often rooted in , but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four. Yet, by doing so, the counselor risks the perpetuation of maladaptive interactive patterns and the adverse effects on development that have already been affected on the child's end of the relationship. Therefore, contemporary thinking on working with this young age group has leaned towards working with parent and child simultaneously within the interaction, as well as individually as needed. Computer-supported psychotherapy Research on computer-supported and computer-based interventions has increased significantly over the course of the last two decades. The following applications frequently have been investigated: * Tele-therapy / tele-mental health: In teletherapy classical psychotherapy is provided via modern communication devices, such as via videoconferencing. * Virtual reality: is a computer-generated scenario that simulates experience. The immersive environment, used for simulated , can be similar to the real world or it can be fantastical, creating a new experience. * Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements. * Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or elements. The feasibility of such interventions has been investigated for individual and group therapy. Effects Evaluation There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated by or more individualized methods. One issue with trials is what to use as a treatment group or non-treatment . Often, this group includes patients on a waiting list, or those receiving some kind of regular non-specific contact or support. Researchers must consider how best to match the use of inert tablets or sham treatments in in pharmaceutical trials. Several interpretations and differing assumptions and language remain. Another issue is the attempt to standardize and manualize therapies and link them to specific symptoms of diagnostic categories, making them more amenable to research. Some report that this may reduce efficacy or gloss over individual needs. Fonagy and Roth's opinion is that the benefits of the evidence-based approach outweighs the difficulties. There are several formal frameworks for evaluating whether a psychotherapist is a good fit for a patient. One example is the Scarsdale Psychotherapy Self-Evaluation (SPSE). However, some scales, such as the SPS, elicit information specific to certain schools of psychotherapy alone (e.g. the superego). Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice. Psychodynamic therapists in particular believe that evidence-based approaches are not appropriate to their methods or assumptions, though some have increasingly accepted the challenge to implement evidence-based approaches in their methods. Outcomes Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions. One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments". The handbook states that there is "little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes". Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as ; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions. Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the of research results and the ability to generalize from them to practicing therapists. However, specific therapies have been tested for use with specific disorders, and regulatory organizations in both the UK and US make recommendations for different conditions. The Helsinki Psychotherapy Study was one of several large long-term clinical trials of psychotherapies that have taken place. Anxious and depressed patients in two short-term therapies (solution-focused and brief psychodynamic) improved faster, but five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies. Meta-analyses have established that Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression. A 2014 meta analysis over 11,000 patients reveals that Interpersonal Psychotherapy (IPT) is of comparable effectiveness to CBT for depression but is inferior to the latter for eating disorders. For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4000 patients. Mechanisms of change It is not yet understood how psychotherapies can succeed in treating mental illnesses. Different therapeutic approaches may be associated with particular theories about what needs to change in a person for a successful therapeutic outcome. In general, processes of and have long been held to play an important role. One theory combining these aspects proposes that permanent change occurs to the extent that the neuropsychological mechanism of is triggered and is able to incorporate new emotional experiences. Adherence Patient to a course of psychotherapy—continuing to attend sessions or complete tasks—is a major issue. The dropout level—early termination—ranges from around 30% to 60%, depending partly on how it is defined. The range is lower for research settings for various reasons, such as the selection of clients and how they are inducted. Early termination is associated on average with various demographic and clinical characteristics of clients, therapists and treatment interactions. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy. Most psychologists use between-session tasks in their general therapy work, and cognitive behavioral therapies in particular use and see them as an "active ingredient". It is not clear how often clients do not complete them, but it is thought to be a pervasive phenomenon. From the other side, the adherence of therapists to therapy protocols and techniques—known as "treatment integrity" or "fidelity"—has also been studied, with complex mixed results. In general, however, it is a hallmark of evidence-based psychotherapy to use fidelity monitoring as part of therapy outcome trials and ongoing quality assurance in clinical implementation. Adverse effects Research on of psychotherapy has been limited for various reasons, yet they may be expected to occur in 5% to 20% of patients. Problems include deterioration of symptoms or developing new symptoms, strains in other relationships, and therapy dependence. Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable. Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice. General critiques Some critics are skeptical of the healing power of psychotherapeutic relationships. Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners, instead favoring either nonprofessional help or biomedical treatments. Others have pointed out ways in which the values and techniques of therapists can be harmful as well as helpful to clients (or indirectly to other people in a client's life). Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping—all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy. On the other hand, some argue psychotherapy is under-utilized and under-researched by contemporary psychiatry despite offering more promise than stagnant medication development. In 2015, the US allocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded by ), despite plentiful evidence they can work and that patients are more likely to prefer them. Some Christians, such as theologian , have argued that successful therapeutic relationships, based on true acceptance of the client as a human being without contingency, require a theological assumption, an ontological acceptance of God. Further critiques have emerged from , and sources. Key to these is the issue of . In this regard there is a concern that clients are persuaded—both inside and outside the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined. Critics suggest that we idealize the situation when we think of therapy only as a helping relationship—arguing instead that it is fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified, and that while it is seldom intended, the therapist–client relationship always participates in society's power relations and political dynamics. A noted academic who espoused this criticism was . References Category:Psychology